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In the 13 years I have worked in school health I am amazed at the increase in the incidence of food allergies in children. When I started in a district of just over 4,000 students, we had one maybe two children with a food allergy. In that same district there are now about 100 children with a documented serious food allergy. While there are lots of theories trying to explain the change, no sole cause can be identified. Unfortunately, increases in the incidence of severe conditions at school has not seen an accompanying recognition of the need to place full time nurses at all schools in our country.
For those of you working in schools with children having allergies, there are some important things to know. First, a food intolerance is not the same as a food allergy. Food intolerance can cause symptoms that are undesirable but are not the signs of an allergy and does not put a person at risk for anaphylaxis, which is a life threatening condition. I have had parents make requests for their children not to receive particular food items because of unpleasant side effects. For example, I myself do not eat onions. I CAN eat them, but the stomach pain they cause afterwards doesn’t make it worth the experience. I happen to love onion rings but they don’t love me back. The last time I spent two days with a very unhappy stomach my husband just shook his head and said “why do you do this??” It was a good question, and I’ve tried to avoid the same consequences ever since. Food intolerances usually comes on gradually, may only happen when a lot of the food is eaten, may only happen if the food is eaten often and most importantly, are not life threatening. Food allergies on the other hand are different, they usually come on suddenly, a small amount of food can trigger a reaction, the reaction happens each time the food is eaten and CAN be life threatening.
It is important to know the difference because quite obviously, the focus and obligation of the school is to be aware and prepared to intervene should a child suffer from food allergies. Hopefully, your school is staffed with a Registered Nurse who can follow up with parents and health care providers to know if a child has an allergy versus an intolerance to certain foods and a plan is in place to avoid exposure and to intervene if exposure were to occur. Any food can cause an allergy but there are eight “most common” foods that account for 90% of all food allergy reactions in the United States. They include: peanuts, tree nuts, milk, eggs, wheat, soy, fish and shellfish. We tend to hear most about allergy to peanuts and tree nuts. The reason is that most of the other allergens have to be eaten to cause severe reactions. Peanuts and tree nuts are a little different. For those with severe allergies, coming into contact with the oil from these products can have devastating consequences. Peanuts and tree nuts have oils that can remain on surfaces. If a child with a severe nut allergy touches that oil and then touches a mucous membrane (such as their mouth) then they can STILL be exposed to the allergen and have a serious, perhaps life-threatening reaction.
So how do you prepare your school or classroom? First of all, you will likely receive pressure to make your school or class “nut free” . This has become a popular trend that is not supported by research or national guidelines. It sounds like a great idea, and many districts adopt this designation in a well-intentioned manner to help parents feel better about their child attending school. Unfortunately, it’s a very dangerous approach. How often do we tell parents of children allergic to bees that our school/district is a “bee free” district? The answer is never, we would not label our school as such because it’s a promise that’s impossible to uphold. I look at “nut free” in the same way. Until we can control what every person brings onto a campus every day of the year- we cannot safely call our schools nut free. I do advocate for schools to be “nut safe”. That means we take measures to control potential exposures for children on an individual level by taking steps to minimize risk for each child individually. Nut oils can be a part of many products- sauces, nougats, ethnic foods, granola etc. there are even potting soils that contain peanut oil. Unless every person checks every label of every product brought onto campus every day, a school is not “nut free”.
It’s not just nuts- any life threatening allergen needs to be addressed, but peanut and tree nut allergies are more risky in a school setting because of the potential contact exposure. Milk, wheat fish, shellfish and soy cause reactions when ingested so the diligence needs to lie in preventing children from eating foods containing these ingredients.
So where do you begin? I recommend the following actions, and that your school/district have a policy for addressing food allergies:
1. Develop a Food Allergy and Anaphylaxis Emergency Care Plan (formerly a food allergy action plan) for every child-http://www.foodallergy.org/document.doc?id=234 (as a note, most children with severe allergies would qualify for a 504 plan under section 504 of the Rehabilitation Act- those plans are not discussed here today)
2. Educate yourself, educate your peers, educate students– learn about food allergies and how you can minimize student’s risk for exposure- take the Back to School online course designed for school personnel http://allergyready.com/
For elementary students there is a wonderful video called “Binky Goes Nuts” that explains food allergies. It is available for $9.99 and is a wonderful tool to educate children! http://shop.pbskids.org/binky-goes-nuts-dvd.html
Lots of additional school resources can be found at: http://www.foodallergy.org/resources/schools
3. Control the environment– post signs on your door and in your classroom saying “peanut free zone” or “nut free zone”. If the parent of a child with life threatening allergies is agreeable, send a letter home to all kids in the class asking that they not to send foods containing the allergen (particularly peanuts and tree nuts) to school with their child. This is difficult to enforce so don’t expect that all parents will check labels and avoid sending these products! Don’t rely on others to look out for the child in your care. Offer a separate seating area at lunch, OR if the parent/child prefers, designate an adult to wipe down tables and check what the students around the child with allergies are eating. Your entire class should wash their hands before returning to the classroom (as they could have peanut or tree nut oils on their hands). Hand sanitizers do not remove this oil and hand washing is recommended action.
4. Be able to respond– Ask the school nurse to train you on use of the epi pen. Most all states have laws requiring training on the administration of medication from those without a nursing license. In a school setting you should be trained to use the device. The epi pen should be available for the student at all times. It should never be locked in the nurses office or up front somewhere it can be forgotten. For small children I encourage putting it in an emergency bag that travels with the class. We often have even younger children with severe allergies carry their epi in a cinch pack or other bag that fits on his/her back and goes from class to class. There are new Auvi-Q injectors that talk you through step-by-step what to do when you pull off the cap! Technology has come a long way!!
5. Watch for Bullying– Be prepared and on the outlook for bullying. It happens in lots of ways, so make sure that children in your classroom aren’t isolated or outcast due to their condition. In my experience, most of the time the children do well in understanding the issue. It’s the adults who minimize the hazards of exposure.
And finally, just a few other thoughts. Pay attention to recess, vending machines, and policies regarding home made treats. Recently a school nurse approached me because classes at her elementary were having a common recess period and were eating snacks on the playground. The snacks were coming from home and from a vending machine. It was an easy fix by changing the rules a bit to say the snack should be eaten before going outside and also the items in the vending machine are not allowed to contain nut products. But if she hadn’t been looking to see everywhere kids could have food it could have been easily missed.
Food allergies are a very real part of everyday life. Data now shows about 1 in 12 children have a serious food allergy so it’s something you will encounter eventually (if you haven’t already) in your schools. Keep you attention focused on each child at an individual level and don’t think quick “school wide” policies are the best way to keep children safe. It takes diligence and ongoing monitoring as do most things in the world of education!!